Organization
CLEMENTINE TWIN LAKES, LLC
Active
Other names
Clementine Fairfax
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MIKE BAGLEY (CHIEF FINANCIAL OFFICER)
(305) 663-1876
Entity
Organization
Contact information
Practice address
11329 HENDERSON RD, FAIRFAX STATION, VA 22039-2314
(305) 663-1876
Mailing address
6100 SW 76TH ST, SOUTH MIAMI, FL 33143-5002
(305) 663-1876
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
323P00000X
Psychiatric Residential Treatment Facility
Primary
—
—
Other
Enumeration date
03/05/2021
Last updated
10/16/2025
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